Dr. A. wanted the abdomen prepped in standard fashion with
betadine applied 3 times. The
betadine was applied from the midline-axilla down to (but not including) the
pubic symphysis and down to the table at the sides.
[Bib: D page 76.]
MEDICATIONS/IRRIGATIONS:
(LIST MEDICATION AND ROUTE OF ADMINISTRATION)
.9% saline via hanger
H2O 1000 mL
.9% saline 1000 mL for injection
Syringe 10 cc luerlock
Syringe 20 cc luerlock
Syringe 30 cc luerlock
Leurlock plug m/f
A ½ inch needle
0.25% Bupivacaine with Epinephrine
[PIC Sheet.]
SPECIAL
EQUIPMENT:
(CATHETERS, DRAINS, PACKING)
- Two 5 mm ports
- Two 10 mm ports
- Three 5 mm ratcheted graspers
- One 5 mm scissor (Metz)
- One 5 mm hook cautery
- One 5 mm curved dissector
- One 10 mm claw grasper
- One entrapment sack
- One loop ligature
- Video cart
- C02 insufflator
- Slave monitor
- A seal
- Disposable clip appliers (one medium, one large)
- 2000 cc suction canister
- Foley catheter 18 Fr with urimeter kit
- Scope warmer
- Suction apparatus
[Bib: A page 185.]
POSITIONING
PATIENT POSITIONING:
Supine. Arm on
armboard.
OR BED POSITION:
The table was initially placed in Trendelenburg between 5
and 10 degrees to facilitate the establishment of the
C02-pneumoperitineum. Then the
patient was positioned in a 30 to 40 degree Reverse Trendelenburg and was
further rotated to the left by 15 – 20 degrees. These movements/repositionings allowed the colon and
duodenum to fall away from the liver’s edge and the falciform ligament and the
liver (both lobes) to be examined.
The inferior margin of the liver was also more easily visualized so as
to locate the gallbladder. In most
surgeries the gallbladder is visible beyond the edge of the liver but,
sometimes, the gallbladder can only be seen after adhesions are removed and/or
after elevating the liver.
[Bib: B page 90.]
POSITIONING SUPPLIES AND EQUIPMENT:
Adjustable OR bed
Armboards
Footstool
[PIC Sheet]
DRAPPING
PROCEDURE:
Squared off towels around the abdomen. Laparotomy drape /sheet with tape
removed.
[Bib: D page 76.]
DESCRIBE
SURGICAL PROCEDURE:
(IF AN ORGAN(S) WAS/WERE REMOVED, WHAT STRUCTURES WERE
LIGATED TO REMOVE THE ORGAN(S)?)
(WHAT INSTRUMENTS WERE USED?)
(COUNTS?)
ANATOMY:
See attached drawings.
[Bib: E pages 12 – 39.]
COUNTS:
- When all items open on backtable and before mayo set-up.
- Closing 1: at closing of peritoneum/first layer of cavity.
- Closing 2: at closure of fascia.
- Closing 3: initiation of skin closure.
Port Placement - CO2-pneumoperitineum 10 mm Trocar
A CO2-pneumoperitineum was created to facilitate safe
placement of trocars into the abdomen; 15 mmHg is a conventional benchmark.[1]
The CO2-pneumoperitineum can be created using either an open or closed
technique.[2] If hemodynamic compromise were to
develop, the CO2-pneumoperitineum would be emptied until vital signs return to
normal.
At the infraumbilical skin fold an incision of approximately
1.5 cm horizontally was made to
place the CO2-pneumoperitineum port.
Next, the retroperitoneum posterior to the umbilicus and the
pelvis were viewed to ensure there was no injury resulting form the
trocar/sheath with a 10 mm laparoscope/camera. While there, the pelvic viscera, anterior surface of the
intestines, omentum and stomach were visualized and no abnormalities were
noted.
Two 5 mm Subcostal Ports
The surgeon next placed two 5mm subcostal ports in the upper
right quadrant.[3]
The first port was placed in the anterior-to middle axillary
line between the 12th rib and the iliac crest inferior to the
gallbladder fundus/liver edge.
The second 5 mm port was placed midway between he axillary
sheath and the xiphoid process.
These two ports allowed the use of grasping forceps to
retain/secure the gallbladder. The
lateral grasping forceps were used to elevate the liver’s edge to clearly
expose the fundus of the gallbladder.
The dissecting forceps were then used to raise the most dependent
portion of the fundus. The
grasping forceps were then used to push laterally and cephaladly to roll up the
entire right lobe of the liver so as to expose the porta hepatis and the
gallbladder. Adhesions in this
area are generally avascular and were lysed bluntly with dissecting forceps by
slowly stripping them in the direction of the infundibulum; any vascular
adhesions would be lysed with the hook cautery.
After the infundibulum was exposed, grasping forceps were
placed through the midclavicular trocar for traction on the neck of the
bladder.
The Second 10 mm Trocar
The last trocar was placed through a longitudinal incision
in the midline of the epigastrium near the location of the gallbladder (the
size of the left liver lobe can also influence placement). This trocar was angled to the right of
the falciform ligament aiming toward the gallbladder.
Exposure
The fundus was now retracted superiorly to the
infundibulum. The gallbladder was
placed under tension and away from the common bile duct in the inferolateral
direction. With the fundus and
neck of the gallbladder under tension, a fine-tipped dissecting forcep was used
to gently pull away the overlying fibroareolar structures from the gallbladder
infundibulum and Hartmann’s pouch starting on the gallbladder and pulling the
tissue toward the porta hepatis.
http://louis-j-sheehan.us/ImageGallery/CategoryList.aspx?id=a1206a74-5f7f-443f-97f5-9b389a4d4f9e&m=0
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Dissection[4]
The peritoneum was lysed. The hepatocystic triangle (a.k.a. Calot’s triangle) was
placed under tension and exposed by retracting the gallbladder infundibulum
inferiorly and laterally while pushing the fundus superiorly and medially. Often there is a lymph node overlying
the cystic artery which, if there, is removed; if so, electrical current is
used to achieve hemostasis.
The infundibulum of the gallbladder was stretched superiorly
and medially even as the fundus was pushed superiorly and laterally to expose
the reverse of the hepatocystic triangle (the area between the cystic duct, the
common hepatic duct, and the right lobe of the liver). It was critical to precisely locate the
junction between the infundibulum and the origin of the cystic duct. The tip of the hooked-shaped cautery
was used to probe and expose the duct.
The cystic artery is often separated from the surrounding tissue now
(but can be separated later depending upon the individual’s anatomy). The cystic duct was now dissected as it
was anteriorly in the field.
Some surgeons now perform a static or fluoroscopic
cholangiography for evaluation of the stones at this juncture. (I did not see
any of this.)
Cystic Duct
The Cystic duct was then doubly clipped[6]
near its junction with the common bile duct and then was divided. Care was taken to avoid injuring
surrounding structures with the clips.
Great care was taken to avoid clipping the common bile duct; if this
were to prove to be too risky, a loop or suture would have been used instead of
clips.
The infundibulum of the gallbladder was placed under tension
and the cystic duct was bluntly dissected, then clipped proximally and distally
and divided by sharp dissection.
Care was taken to not confuse the right hepatic artery with
the cystic artery.
The ligations of the duct and cystic artery were examined to
confirm that neither bile nor blood is leaking, that the clips are secure, and
that the clips close the entire lumen without attaching any of the adjacent
tissue. Irrigation and suctioning
were used to remove debris. The
grasping forceps in the midclavicular trocar were repositioned on the proximal
end of the gallbladder at Hartman’s pouch. The infundibulum was retracted superiorly and laterally and
also away from its hepatic bed.
The tissues that tethered the neck of the gallbladder were inspected to
ensure no other sizeable tubular structures were in this immediate area. The hepatic fossa was divided and
coagulated (both small vessels and lymphatics were coagulated). On rare
occasion, a blood vessel or small duct will require the placement of another
clip.
Gallbladder Dissection
As necessary, any tears in the gallbladder wall may be
clipped or looped to prevent stone leakage or additional bile leak.
As always (i) the hepatic fossa and porta hepatis were
monitored for any blood and/or bile leakage, (ii) the clips were monitored for
stability, and (iii) small bleeding points were coagulated with electrocautery,
and (iv) the liver was examined for hemostasis.[8] Further, irrigation assists with the
visualization at this juncture.
The gallbladder was then separated with electrocautery. With the tissue connecting the
gallbladder to the fossa placed under tension, the surgeon used electrocautery
(typically the hook) set at 25 (sometimes 30) to divide and coagulate the
tissue.
The dissection of the gallbladder continued from the
infundibulum to the fundus with intermittent repositioning of the midclavicular
grasping forceps proximal to the plane of dissection to allow maximal
contraction until the gallbladder was attached only by a narrow and thin
tissue.
Finally, the little remaining attachments to the gallbladder
were lysed.
Removal
The laparoscope was transferred to the midepigastric
port.
The gallbladder was removed via the umbilicus under direct
visualization from the laparoscope.
The umbilical port was used because there are no thick muscle layers at
this point and there is only one fascial plane that must be crossed. Additionally, if an
incision needs to be enlarged because of the size of the stones, extending the
umbilical incision causes less postoperative pain than does extending any of
the other incisions.
At Harrisburg, I have always seen the use of an entrapment
bag.[9]
The grasper forceps were used to place the gallbladder into the entrapment
sack. The gallbladder-containing
entrapment sack was then withdrawn through the umbilical port. This left the neck of the gallbladder
on the anterior abdominal wall and the distended fundus within the abdominal
cavity.
If the gallbladder were to be enlarged due to stones or
bile, a suction catheter could have been used for aspiration before the
entrapment sack’s withdrawal. As
an alternative, stone forceps could have been placed into the gallbladder to
extract or crush overly large stones.
Rarely, the incision must be enlarged to remove larger stones.
The gallbladder was a specimen.
[Bib: A pages 186 – 191, B pages 90 – 94, C pages 192 –
194.]
BIBLIOGRAPHY
A =
Laparoscopic Surgery,
Principles and Procedures, 2nd Edition. Edited by D.B. Jones, J.S. Wu, and N.J. Soper. Pages 181 – 196 (2004).
B=
Laparoscopic Surgery
of the Abdomen, B.V. MacFayden, Jr. as Senior Editor. Pages 87 – 99 (2004).
C=
Laparoscopic Surgery,
by Cueto-Garcia, Jacobs and Gagner. Pages 191 – 195 (2003).
D=
Pocket Guide to the
Operating Room, 2nd Edition. M.A. Goldman. Pages 74 – 79. (1996).
E=
Atlas of Minimally
Invasive Surgery, by Jones (MD), Maithel (MD) and Schneider (MD). Pages 12 – 39 (2006).
Louis J Sheehan
Louis J Sheehan, Esquire
http://louis2j2sheehan.bloggerteam.com/ http://blog.myspace.com/index.cfm?fuseaction=blog&pop=1&indicate=1http://pub25.bravenet.com/journal/post.php?entryid=22156
Louis
J Sheehan Esquire
The holidays are over. Resolutions are
wearing thin. It's a time of year when many people wonder if they have a
drinking problem.
More than 30% of Americans engage in
risky drinking at some point in their lives, according to the National
Institute on Alcohol Abuse and Alcoholism. But there's no consensus on exactly
what an "alcoholic" is. Even Alcoholics Anonymous relies on
alcoholics to diagnose themselves.
Researchers have made up dozens of
screening tests over the years. According to one developed for Johns Hopkins
University Hospital years ago that still pops up on the Web, I'm
"definitely an alcoholic" because I answered yes to at least three of
20 questions: I "crave a drink at a definite time of day" (evenings,
mostly) and drink alone (sometimes) and drink to "escape from worries or
troubles" (doesn't everyone who drinks?).
But Alcoholscreening.org3 says I'm
"below the range usually associated with harmful drinking or
alcoholism" since I have only a glass or two of wine when I drink.
The authoritative American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV,
separates alcohol abuse from alcohol dependence, based partly on the problems
the drinking causes. You qualify for a diagnosis of "abuse" if you've
done any one of these in the past year: drunk alcohol in hazardous situations,
like driving; kept drinking despite social or interpersonal problems; had legal
problems related to alcohol or failed to fulfill major obligations at work,
school or home because of drinking.
You've moved on to
"dependence" if you've done any three of these seven: drunk more or
longer than you intended; been unable to cut down or stop; needed more alcohol
to get the same affect; had withdrawal symptoms without it; spent more time
drinking or recovering; neglected other activities or continued to drink
despite psychological or physical problems.
Experts long believed that abuse
progressed to dependence, which almost inevitably became chronic and relapsing
-- but that was based on observing severely addicted people in treatment
programs. Several large new surveys have shown that drinking patterns in the
general population are much more varied, with milder forms of dependence. Some
43% of daily heavy drinkers don't fit into either DSM-IV category, according to
one big national sample, even though they are setting themselves up for serious
health and addiction problems.
Abuse vs. Dependence
"Some people will abuse alcohol
-- driving drunk, for example -- but they only drink heavily once a month. They
can remain stable for a long time and not progress to dependence," says
Mark L. Willenbring, director of the division of treatment and recovery
research at the NIAAA. "And people can be dependent and not have abuse
problems at all. They're successful students. They're good parents, good
workers. They watch their weight. They go the gym. Then they go home and have
four martinis or two bottles of wine. Are they alcoholics? You bet. And the
goal is to get treatment for these folks, earlier, that is acceptable and
attractive and effective."
To that end, some experts want the
DSM-V -- the new edition now being compiled -- to combine abuse and dependence
into a single "alcohol-use disorder" that ranges in severity, taking
into account harmful drinking patterns and other symptoms. The aim is for
simmering problems to be spotted sooner.
As one former treatment counselor
says, "The conventional wisdom held that alcoholics had to hit bottom
before they could get better. We'd like to raise that bottom so that people
don't have to fall as far before they get help."
[Health]
Many heavy drinkers are very
high-functioning -- until they can't function anymore. "Alcoholics can be
high achievers in the short run, because they're driven and compulsive,"
says Charlie, a New York attorney who, like all AA members, wants to remain
anonymous. Charlie was drinking about a fifth of Johnnie Walker most nights
when it began to show. "I'd tell my secretary I was in a meeting with a
client, but I'd be home and only starting to feel human by about noon. Then I'd
try to do eight hours of work in four hours," he says. This went on for
seven years, until he finally went into rehab. He's been sober now for 26
years.
Charlie says many heavy drinkers,
especially those who grew up around alcoholics, set a private benchmark in
their denial. "They say to themselves, 'As long as I'm not making a fool
of myself in a bar, or drinking in the morning, or as long as I'm still showing
up for work, then I'm not an alcoholic.'"
You know you've hit bottom, he adds,
"when your behavior spirals downward faster than you can lower your
standards."
Thinking You're Immune
Ruth, a nursing supervisor in Las
Vegas, hid her quart-a-day whiskey habit from work for about five years --
"until my husband and my employer both invited me out of those positions
at the same time," she says. "That got my attention."
Both of Ruth's parents died of
alcohol-related illnesses, but she thought her medical training would protect
her from getting seriously addicted. Doctors and clergy who drink heavily often
have the notion that they are somehow immune to the problems they see in
others, she observes, and affluent people can pay others to take care of them.
"People with less money and less education often get the message faster,"
she says, now that she's been sober for 37 years.
NIAAA officials say that in
recognizing a drinking problem, the label "alcoholic" is less
important than harmful patterns of drinking, which they describe as drinking
too much, too fast or too much, too often.
Too much, too fast means consuming
more than four drinks in two hours for men, and more than three in two hours
for women. That's a level that, on average, makes people legally drunk and
impairs brain function. (A standard U.S. drink, by the way, is 12 oz. of beer,
5 oz. of wine or a 1.5 oz. shot of 80 proof spirits, according to government
agencies.)
Even if you stay within those limits
each day, you can be drinking too much, too often, if you have more than 14
drinks a week for men, and more than 7 for women. That's the kind of chronic
use that raises the risks of a long list of health problems, including liver
and cardiovascular disease, pancreatitis, dementia, depression and numerous
cancers.
How those weekly drinks are
distributed is also important. "If you drink seven drinks in two days,
that's hazardous -- you're drunk two days a week," says Ting-Kai Li, the
NIAAA's director. "If you drink two a day for seven days, that's not
harmful. In fact, it may even be beneficial for some people, lowering their
cardiovascular risk."
Individual responses to alcohol vary,
of course, based on genetics, brain chemistry, metabolism and other factors.
Your risk is already elevated if you have a family history of alcohol abuse,
have health problems such as depression, take certain medications or you
started drinking at an early age. "If you have a family history or other
co-morbidity, then the general advice is, don't drink at all," says Dr.
Li.
If you're worried that you may be
drinking too much, you've already met a key criterion on some screening tests.
(Like the old saying about mice in your house, if you think you have a problem,
you probably do.)
Counting drinks very carefully to stay
within the limit can be a sign of trouble too, says Ruth. "The glass keeps
getting bigger and bigger or you forget to add the mixer." She suggests
trying to go 30 or 60 days without drinking. "If it doesn't bother you,
you're OK. But if you're desperate for that 30 days to end, or you can't make
it, then get help." She suggests trying one of AA's public information
meetings. "If you're not an alcoholic, you can't catch it from them,"
she says.
Your family doctor is another place to
start. The NIAAA recently issued a guide for primary-care physicians
(www.niaaa.nih.gov/guide4) to enlist their help in spotting alcohol problems.
It starts with a single screening question: How many times in the last year
have you had more than five drinks (four for women) in a day? If the answer is
even once, doctors are advised to discuss the risks of harmful drinking with
their patients, along with steps patients can take to cut back, including new
medications that can help curb alcohol cravings.
In Remission
The encouraging news from the NIAAA's
recent research is that many people do cut down or quit on their own.
"That's the real mind blower," says Dr. Willenbring. "Only about
15% of the people who develop alcohol dependence in their lifetime have the
severe, relapsing form. Most people -- 72% -- have a single episode [of
addiction] lasting on average three or four years and then they go into
remission and stay there. A lot of them are abstaining." For many people,
that spate of heavy drinking happens in college -- the peak years are 18 to 24,
says Dr. Willenbring. "Then they mature out of it and get on with their
lives."
For those who don't, alcoholism,
however it's defined, is still a profound problem, and the third leading cause
of preventable death in the U.S., after smoking and obesity. But being aware of
your risks and cutting down now if you need to may prevent you from becoming
one of those statistics.
Doctoral student Catherine Powers
traveled to fossil sites around the world, including this one in Greece, to
study ancient bryozoan marine communities.
The greatest mass extinction in
Earth’s history also may have been one of the slowest, according to a study
that casts further doubt on the extinction-by-meteor theory.
Creeping environmental stress fueled
by volcanic eruptions and global warming was the likely cause of the Great
Dying 250 million years ago, said USC doctoral student Catherine Powers.
Writing in the November issue of the
journal Geology, Powers and her adviser David Bottjer, professor of earth
sciences at USC College, describe a slow decline in the diversity of some
common marine organisms.
The decline began millions of years
before the disappearance of 90 percent of Earth’s species at the end of the
Permian era, Powers shows in her study.
More damaging to the meteor theory,
the study finds that organisms in the deep ocean started dying first, followed
by those on ocean shelves and reefs, and finally those living near shore.
“Something has to be coming from the
deep ocean,” Powers said. “Something has to be coming up the water column and
killing these organisms.”
That something probably was hydrogen
sulfide, according to Powers, who cited studies from the University of
Washington, Pennsylvania State University, the University of Arizona and the
Bottjer laboratory at USC.
Those studies, combined with the new
data from Powers and Bottjer, support a model that attributes the extinction to
enormous volcanic eruptions that released carbon dioxide and methane,
triggering rapid global warming.
The warmer ocean water would have lost
some of its ability to retain oxygen, allowing water rich in hydrogen sulfide
to well up from the deep (the gas comes from anaerobic bacteria at the bottom
of the ocean).
If large amounts of hydrogen sulfide
escaped into the atmosphere, the gas would have killed most forms of life and
also damaged the ozone shield, increasing the level of harmful ultraviolet
radiation reaching the planet’s surface.
Powers and others believe that the
same deadly sequence repeated itself for another major extinction 200 million
years ago, at the end of the Triassic era.
“There are very few people that hang
on to the idea that it was a meteorite impact,” she said. Even if an impact did
occur, she added, it could not have been the primary cause of an extinction
already in progress.
In her study, Powers analyzed the
distribution and diversity of bryozoans, a family of marine invertebrates.
Based on the types of rocks in which
the fossils were found, Powers was able to classify the organisms according to
age and approximate depth of their habitat.
She found that bryozoan diversity in the
deep ocean started to decrease about 270 million years ago and fell sharply in
the 10 million years before the mass extinction that marked the end of the
Permian era.
But diversity at middle depths and
near shore fell off later and gradually, with shoreline bryozoans being
affected last, Powers said.
She observed the same pattern before
the end-Triassic extinction, 50 million years after the end-Permian.
Powers’ work was funded by the
Geological Society of America, the Paleontological Society, the American Museum
of Natural History and the Yale Peabody Museum, and supplemented by a grant
from USC’s Women in Science and Engineering program.
“The reasonable man adapts himself to
the world; the unreasonable one persists in trying to adapt the world to
himself. Therefore all progress depends on the unreasonable man.”
—George Bernard Shaw, Man and Superman
[1] Higher
insufflation might be required in morbidly obese patients. Pressures below 15 mmHg reduce the risk
of cardiorespiratory problems.
[2] Open
insertion of the CO2-pneumoperitineum port takes longer, but extraction of the
gallbladder at the end of the operation is easier. Open insertion is especially helpful in a patient (i) who
has had previous periumbilical incisions, and (ii) in whom insertion of a
Veress needle proves to be difficult,
and (iii) in those with gallstones thought to be larger than 2.5 cm,
and (iv) in those who have acute
cholecystitis.
[3] A Veress
needle may first be placed at the proposed site(s) to determine if the location
and angle insertion are optimal.
[4]
Countertension to the plane of dissection facilitates dissection.
[5] An injection
of radiopaque material is used to outline the bile ducts and then a an x-ray
image is taken.
[6] The surgeon
strives to apply the clips at right angles to avoid later slippage.
[7]
Electrocautery should not be used to divide the cystic artery as the current
might be transmitted to the proximal clips (which can cause hemorrhage and/or
necrosis).
[8] Any small
liver lacerations can be stopped with direct pressure or electrocauterization
or even with a topical hemostatic agent; clips are discouraged for purposes of
stopping hemorrhage to avoid damaging any structures
[9] However,
once the bag broke during removal but the gallbladder was then simply removed
hanging out the end of the bag’s long handle.
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